Preconception Care in Preconception Care in the Context of the Context of Maternal Mortality Maternal Mortality Ashlesha K. Dayal, MD Ashlesha K. Dayal, MD Assistant Professor Obstetrics and Assistant Professor Obstetrics and Gynecology and Women’s Health Gynecology and Women’s Health Albert Einstein College of Medicine/ Albert Einstein College of Medicine/ Montefiore Medical Center Montefiore Medical Center Bronx, NY Bronx, NY How to Save a Life
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Preconception Care in the Context of Maternal Mortality Ashlesha K. Dayal, MD Assistant Professor Obstetrics and Gynecology and Women’s Health Albert Einstein.
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Preconception Care in the Preconception Care in the Context of Maternal Context of Maternal
MortalityMortality
Ashlesha K. Dayal, MDAshlesha K. Dayal, MDAssistant Professor Obstetrics and Gynecology and Assistant Professor Obstetrics and Gynecology and
Women’s HealthWomen’s Health
Albert Einstein College of Medicine/ Montefiore Albert Einstein College of Medicine/ Montefiore Medical CenterMedical Center
Bronx, NYBronx, NY
How to Save a Life
Renal TransplantRenal Transplant29 y/o P0 presents to MFM for 129 y/o P0 presents to MFM for 1stst PNV at 15 wks PNV at 15 wksSLE, renal failure, dialysisSLE, renal failure, dialysis1998 Renal transplant from sister 1998 Renal transplant from sister – Failed after 6 days, secondary to thrombosisFailed after 6 days, secondary to thrombosis
1998 21998 2ndnd renal transplant from husband renal transplant from husband – – stable on immunosuppresive meds for 6 yearsstable on immunosuppresive meds for 6 years
Nephrologist stops meds at 7 wks of pregNephrologist stops meds at 7 wks of pregAbnormal u/a & inc creatinine – 10 wksAbnormal u/a & inc creatinine – 10 wksRenal bx in pregnancy to r/o rejection – 10 wksRenal bx in pregnancy to r/o rejection – 10 wksHemorrhage from bx – nephrectomyHemorrhage from bx – nephrectomy
Renal TransplantRenal Transplant
Pregnancy on dialysis since 10 wksPregnancy on dialysis since 10 wks
Uncontrollable HTN, seizures at 23 wks, pt Uncontrollable HTN, seizures at 23 wks, pt declines TOP despite risk of maternal declines TOP despite risk of maternal deathdeath
Fetus IUGR (280gm at 24 wks) – IUFDFetus IUGR (280gm at 24 wks) – IUFD
Patient anephric on dialysis, awaits Patient anephric on dialysis, awaits transplanttransplant
The death of a women while The death of a women while pregnant or within one year pregnant or within one year of termination of pregnancy, irrespective of causeof termination of pregnancy, irrespective of cause..
Pregnancy-related death.Pregnancy-related death.The death of a women while pregnant or within one year of The death of a women while pregnant or within one year of termination of pregnancy, irrespective of the duration & site termination of pregnancy, irrespective of the duration & site of the pregnancy, of the pregnancy, from any cause related to or from any cause related to or aggravated by her pregnancy or its managementaggravated by her pregnancy or its management, but not , but not from accidental or incidental causes.from accidental or incidental causes.
Not-pregnancy-related death.Not-pregnancy-related death.The death of a women while pregnant or within one year of The death of a women while pregnant or within one year of termination of pregnancy, due to a cause termination of pregnancy, due to a cause unrelated to unrelated to pregnancypregnancy..
Source: Berg, Atrash, Zane, Barlett. Strategies to reduce pregnancy-related deaths: From identification and review to action. Atlanta: Center for Disease Control and Prevention 2001.
In 2000, 4.1 million women aged 18-44 In 2000, 4.1 million women aged 18-44 made visits to family physiciansmade visits to family physicians
Opportune times for preconception Opportune times for preconception discussions—well woman visit, discussions—well woman visit, negative pregnancy test, follow up negative pregnancy test, follow up visits after spontaneous or voluntary visits after spontaneous or voluntary abortionsabortions
Preconception CarePreconception Care
What is preconception care?What is preconception care?– Risk assessment for a future pregnancyRisk assessment for a future pregnancy– Assessment of broad range of risk factorsAssessment of broad range of risk factors– Timing of this risk assessmentTiming of this risk assessment
Preconception CarePreconception Care
Identifies reducible or reversible risksIdentifies reducible or reversible risks
Maximizes maternal healthMaximizes maternal health
Intervenes to achieve optimal Intervenes to achieve optimal outcomesoutcomes
From March of Dimes Preconception Curriculum
Preconception CarePreconception Care
Reframes IssuesReframes Issues
Adds an anticipatory elementAdds an anticipatory element
Focuses on the impact of pregnancyFocuses on the impact of pregnancy
From March of DimesPreconception Curriculum
Elements of Preconception CareElements of Preconception Care
Focuses on elements which must be Focuses on elements which must be accomplished prior to conception or accomplished prior to conception or weeks thereafter to be effectiveweeks thereafter to be effective– Risk assessmentRisk assessment– Health promotionHealth promotion– Medical and psychosocial interventionsMedical and psychosocial interventions
From March of DimesPreconception Curriculum
Components to Preconception Components to Preconception CareCare
Medical HistoryMedical History
Pychosocial IssuesPychosocial Issues
Physical ExamPhysical Exam
Laboratory testsLaboratory tests
Family HistoryFamily History
Nutritional AssessmentNutritional Assessment
Components to Preconception Components to Preconception CareCare
Medical historyMedical history– Particular medical conditions that lend Particular medical conditions that lend
themselves to Pre-pregnancy managementthemselves to Pre-pregnancy managementDiabetesDiabetes
Obstetrical conditions at high risk---Obstetrical conditions at high risk---incompetent cervix, history of premature incompetent cervix, history of premature rupture of membranes, uterine malformationsrupture of membranes, uterine malformations
Components to Preconception Components to Preconception CareCare
Pychosocial IssuesPychosocial Issues– Screening for Depression—discussion of Screening for Depression—discussion of
medication, therapy and PP depression risk medication, therapy and PP depression risk – Emotional or Physical Abuse--offer confidential, Emotional or Physical Abuse--offer confidential,
safe screening and discussion safe screening and discussion Assess safetyAssess safety
One third of women reporting violence report escalation One third of women reporting violence report escalation in pregnancyin pregnancy
Role of health care providerRole of health care provider
Components to preconception Components to preconception carecare
Laboratory testsLaboratory tests– In patients with particular histories, In patients with particular histories,
antiphospholipid screens best done prior antiphospholipid screens best done prior to pregnancyto pregnancy
Components to Preconception Components to Preconception CareCare
Family HistoryFamily History– Genetic historyGenetic history– Discussion of age-related risksDiscussion of age-related risks– Discussion of disease related risksDiscussion of disease related risks– Carrier screeningCarrier screening– Potential for egg or sperm donation or Potential for egg or sperm donation or
early genetic screeningearly genetic screening
Components to Preconception Components to Preconception CareCare
Nutritional AssessmentNutritional Assessment– Folic Acid for Everyone!! Modifies risk for neural Folic Acid for Everyone!! Modifies risk for neural
Effects of various substance use on Effects of various substance use on pregnancy and fetuspregnancy and fetus
Screening for use and abuseScreening for use and abuse
Referral for treatment Referral for treatment options/programsoptions/programs
Emphasize using pregnancy as Emphasize using pregnancy as motivation for changemotivation for change
Tobacco and PreconceptionTobacco and Preconception
Tobacco: most preventable cause of Tobacco: most preventable cause of LBWLBW– Associations with abruption, placenta Associations with abruption, placenta
previa, preterm deliveryprevia, preterm delivery– Cessation at any time in pregnancy Cessation at any time in pregnancy
improves risksimproves risks– How to offer help with cessationHow to offer help with cessation
Alcohol and PreconceptionAlcohol and Preconception
Most preventable cause of Mental Most preventable cause of Mental Retardation---fetal alcohol syndromeRetardation---fetal alcohol syndromeMost common teratogen exposureMost common teratogen exposureDose related effects---worst outcomes Dose related effects---worst outcomes with “binge drinking”with “binge drinking”Effects can be seen at all stages of Effects can be seen at all stages of pregnancypregnancy
Drug use and PreconceptionDrug use and Preconception
““The failure to address preventable The failure to address preventable maternal disability and death represents maternal disability and death represents one of the greatest social injustices of our one of the greatest social injustices of our times….Women’s reproductive health risks times….Women’s reproductive health risks are are notnot mere misfortunes and unavoidable mere misfortunes and unavoidable disadvantages of pregnancy, but rather, disadvantages of pregnancy, but rather, injustices that societies are able and injustices that societies are able and obliged to remedy…”obliged to remedy…”
Rebecca J. Cook, Bernard M. Dickens, WHO, 2001
Maternal Mortality Ratios per 100,000 Live Births, 2000WHO, United Nations